Title 42, Part 456 — Utilization Control
142 sections
Section 456.1
Basis and purpose of part.
Section 456.2
State plan requirements.
Section 456.3
Statewide surveillance and utilization control program.
Section 456.4
Responsibility for monitoring the utilization control program.
Section 456.5
Evaluation criteria.
Section 456.6
Review by State medical agency of appropriateness and quality of services.
Section 456.21
Scope.
Section 456.22
Sample basis evaluation of services.
Section 456.23
Post-payment review process.
Section 456.50
Scope.
Section 456.51
Definitions.
Section 456.60
Certification and recertification of need for inpatient care.
Section 456.80
Individual written plan of care.
Section 456.100
Scope.
Section 456.101
UR plan required for inpatient hospital services.
Section 456.105
UR committee required.
Section 456.106
Organization and composition of UR committee; disqualification from UR committee membership.
Section 456.111
Beneficiary information required for UR.
Section 456.112
Records and reports.
Section 456.113
Confidentiality.
Section 456.121
Admission review required.
Section 456.122
Evaluation criteria for admission review.
Section 456.123
Admission review process.
Section 456.124
Notification of adverse decision.
Section 456.125
Time limits for admission review.
Section 456.126
Time limits for final decision and notification of adverse decision.
Section 456.127
Pre-admission review.
Section 456.128
Initial continued stay review date.
Section 456.129
Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.
Section 456.131
Continued stay review required.
Section 456.132
Evaluation criteria for continued stay.
Section 456.133
Subsequent continued stay review dates.
Section 456.134
Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
Section 456.135
Continued stay review process.
Section 456.136
Notification of adverse decision.
Section 456.137
Time limits for final decision and notification of adverse decision.
Section 456.141
Purpose and general description.
Section 456.142
UR plan requirements for medical care evaluation studies.
Section 456.143
Content of medical care evaluation studies.
Section 456.144
Data sources for studies.
Section 456.145
Number of studies required to be performed.
Section 456.150
Scope.
Section 456.151
Definitions.
Section 456.160
Certification and recertification of need for inpatient care.
Section 456.170
Medical, psychiatric, and social evaluations.
Section 456.171
[Reserved]
Section 456.180
Individual written plan of care.
Section 456.181
Reports of evaluations and plans of care.
Section 456.200
Scope.
Section 456.201
UR plan required for inpatient mental hospital services.
Section 456.205
UR committee required.
Section 456.206
Organization and composition of UR committee; disqualification from UR committee membership.
Section 456.211
Beneficiary information required for UR.
Section 456.212
Records and reports.
Section 456.213
Confidentiality.
Section 456.231
Continued stay review required.
Section 456.232
Evaluation criteria for continued stay.
Section 456.233
Initial continued stay review date.
Section 456.234
Subsequent continued stay review dates.
Section 456.235
Description of methods and criteria: Continued stay review dates; length of stay modification.
Section 456.236
Continued stay review process.
Section 456.237
Notification of adverse decision.
Section 456.238
Time limits for final decision and notification of adverse decision.
Section 456.241
Purpose and general description.
Section 456.242
UR plan requirements for medical care evaluation studies.
Section 456.243
Content of medical care evaluation studies.
Section 456.244
Data sources for studies.
Section 456.245
Number of studies required to be performed.
Section 456.350
Scope.
Section 456.351
Definition.
Section 456.360
Certification and recertification of need for inpatient care.
Section 456.370
Medical, psychological, and social evaluations.
Section 456.371
Exploration of alternative services.
Section 456.372
Medicaid agency review of need for admission.
Section 456.380
Individual written plan of care.
Section 456.381
Reports of evaluations and plans of care.
Section 456.400
Scope.
Section 456.401
State plan UR requirements and options; UR plan required for intermediate care facility services.
Section 456.405
Description of UR review function: How and when.
Section 456.406
Description of UR review function: Who performs UR; disqualification from performing UR.
Section 456.407
UR responsibilities of administrative staff.
Section 456.411
Beneficiary information required for UR.
Section 456.412
Records and reports.
Section 456.413
Confidentiality.
Section 456.431
Continued stay review required.
Section 456.432
Evaluation criteria for continued stay.
Section 456.433
Initial continued stay review date.
Section 456.434
Subsequent continued stay review dates.
Section 456.435
Description of methods and criteria: Continued stay review dates.
Section 456.436
Continued stay review process.
Section 456.437
Notification of adverse decision.
Section 456.438
Time limits for notification of adverse decision.
Section 456.480
Scope.
Section 456.481
Admission certification and plan of care.
Section 456.482
Medical, psychiatric, and social evaluations.
Section 456.500
Purpose.
Section 456.501
UR plans as a condition for FFP.
Section 456.505
Applicability of waiver.
Section 456.506
Waiver options for Medicaid agency.
Section 456.507
Review and granting of waiver requests.
Section 456.508
Withdrawal of waiver.
Section 456.520
Definitions.
Section 456.521
Conditions for granting variance requests.
Section 456.522
Content of request for variance.
Section 456.523
Revised UR plan.
Section 456.524
Notification of Administrator's action and duration of variance.
Section 456.525
Request for renewal of variance.
Section 456.600
Purpose.
Section 456.601
Definitions.
Section 456.602
Inspection team.
Section 456.603
Financial interests and employment of team members.
Section 456.604
Physician team member inspecting care of beneficiaries.
Section 456.605
Number and location of teams.
Section 456.606
Frequency of inspections.
Section 456.607
Notification before inspection.
Section 456.608
Personal contact with and observation of beneficiaries and review of records.
Section 456.609
Determinations by team.
Section 456.610
Basis for determinations.
Section 456.611
Reports on inspections.
Section 456.612
Copies of reports.
Section 456.613
Action on reports.
Section 456.614
Inspections by utilization review committee.
Section 456.650
Basis, purpose and scope.
Section 456.651
Definitions.
Section 456.652
Requirements for an effective utilization control program.
Section 456.653
Acceptable reasons for not meeting requirements for annual on-site review.
Section 456.654
Requirements for content of showings and procedures for submittal.
Section 456.655
Validation of showings.
Section 456.656
Reductions in FFP.
Section 456.657
Computation of reductions in FFP.
Section 456.700
Scope.
Section 456.702
Definitions.
Section 456.703
Drug use review program.
Section 456.705
Prospective drug review.
Section 456.709
Retrospective drug use review.
Section 456.711
Educational program.
Section 456.712
Annual report.
Section 456.714
DUR/surveillance and utilization review relationship.
Section 456.716
Dur Board.
Section 456.719
Funding for DUR program.
Section 456.722
Electronic claims management system.
Section 456.725
Funding of ECM system.